Synopsis On 01 May 1995, the service vessel VZINA NO. 1 was participating in the towing of the CAVALIER MAXIM and was assisting the SERVICE BOAT II. The crew of the VZINA NO. 1, which was on the port quarter of the CAVALIER MAXIM, hooked the eye of the tow-line over the single towing bitt in the middle of the afterdeck. During the inbound towage toward Louise Basin, the operator of the VZINA NO. 1 tried to turn his boat 180 degrees to port as he intended to let his vessel be drawn backward. When the VZINA NO. 1 executed this manoeuvre, she became girded on her starboard side and was unable to return to the upright. As a result of this and of the momentum of the tow, the VZINA NO. 1 downflooded and capsized. The operator was unable to exit the wheel-house and he lost his life. The Board determined that the capsizing of the VZINA NO. 1 was initially the result of the manner in which the manoeuvre was attempted. In addition, the tow-line used for the towing operation was too short and the angle between the two attachment points was clearly too steep. Since the eye of the tow-line had been hooked over the towing bitt of the VZINA NO. 1, the crew members were unable to keep control of the tow-line at all times, and they were unable to release it in case of emergency. 1.0 Factual Information 1.1 Particulars of the Vessels 1.1.1 Description of the Vessel The VZINA NO.1 was built to be used as a pilot boat in the Port of Qubec. In 1987, her owner had to re-assign the vessel to other tasks such as towage and miscellaneous operations in the Port of Qubec area. The wheel-house is amidship and the afterdeck is fitted with a towing bitt. However, there is no winch or towing hook with automatic tow-abort capability on the afterdeck of the VZINA NO.1. 1.2 History of the Voyage On 01May 1995, at 1322(3), the CAVALIER MAXIM, originating from Petite-Rivire-Saint-Franois, Quebec, under tow by the CAVALIER GRAND FLEUVE, arrived at the harbour limits inbound to Louise Basin to commence berthing procedures. The tug SERVICEBOATII and the service vessel VZINA NO.1 took over from the CAVALIERGRAND FLEUVE Upon their arrival, and as agreed beforehand between the operator of the VZINA NO.1 and the master of the SERVICE BOATII, the latter vessel took the tow-line from the CAVALIER GRAND FLEUVE and positioned herself at the bow of the CAVALIERMAXIM, while the VZINA NO.1 took up position on the port quarter. It was decided to proceed that way to facilitate entry of the CAVALIER MAXIM into LouiseBasin. It had been agreed beforehand that the VZINA NO.1 would remain in that position until it was time to enter Louise Basin. She was then to move away from the CAVALIER MAXIM while controlling that vessel's stern during the entrance into the basin and during the berthing manoeuvres. A tow-line with a bridle had been handed to the CAVALIER MAXIM, but because of the layout of the promenade deck on the passenger vessel, the crew could not accept that tow-line. The crew of the vessel under tow then ran a line out to the VZINA NO.1 from the fairlead aft on the promenade deck. The eye of the tow-line was hooked over the towing bitt on the afterdeck of the VZINA NO.1, and the length of the tow-line between the two vessels was about 10 metres. After a few minor course changes, the SERVICE BOATII called the VZINA NO.1 to ensure that the operation was proceeding smoothly. The VZINA NO.1 informed the tug that she was going under the counter of the CAVALIER MAXIM. The tow-line was not long enough to enable the VZINA NO.1 to move forward and position herself on the port forward quarter of the passenger vessel, and thereby avoid going under the counter. The hull below the curtain plate a few metres above the waterline forms a sharp angle at the quarter of the CAVALIER MAXIM. Shortly after the towing operation began, when the speed of the tow was an estimated two to three knots, the operator of the VZINA NO.1 informed the SERVICE BOATII by radiotelephone that he intended to let his vessel be drawn backward. Before the message was acknowledged by the SERVICE BOATII, the VZINA NO.1 initiated a 180-degree turn to port to take up a stern-to-stern position behind the CAVALIER MAXIM. However, when the VZINA NO.1 had turned through 130 degrees, the tow-line was fully extended, thus applying enough tension to gird the vessel, which was unable to return to the upright. The deck-hand on duty on the afterdeck tried to grab the fire axe to sever the tow-line, but he could not reach it because of the severe list of the vessel. Within one minute, the VZINANO.1 became girded, downflooded, and capsized. The operator was unable to exit the wheel-house. None of the crew members of the CAVALIER MAXIM had remained on the afterdeck to serve as look-outs for the towing operation and tend to the tow-line. The alert was given when the operator of the VZINA NO.1 shouted over the radio to stop pulling, and some people on the CAVALIER MAXIM heard the deck-hand screaming. The Marine Communications and Traffic Services (MCTS) Centre was notified at once by the SERVICEBOATII, which advised that they had pulled one crew member of the VZINANO.1 from the water, but that the other was still missing. Immediately upon receiving the message, the MCTS Centre launched a search and rescue (SAR) operation. The CCGS STERNE, a Canadian Coast Guard (CCG) helicopter and ZODIAC were dispatched to the scene of the accident. The STERNE, which was in the vicinity, arrived on the scene about 15 minutes later, followed shortly by the other units. However, their efforts to save the operator were unsuccessful. A few hours later, divers from a commercial firm retrieved the body of the operator, who had remained in the wheel-house. 1.3 Injuries to Persons The autopsy report established that death was by drowning; the victim sustained no other injury. 1.4 Damage 1.4.1 Damage to the Vessel The VZINA NO.1 was refloated two days later. Damage was limited to the electronic navigation instruments and the engine, which had to be replaced. 1.4.2 Damage to the Environment Environmental damage resulting from the capsizing of the VZINA NO.1 was limited to the spillage of a few litres of diesel fuel, which caused only minor pollution. 1.5 Certification 1.5.1 Vessel The VZINA NO.1 is registered as a pilot boat. The SIC16 inspection certificate issued to the vessel by the CCG on 06April 1995 is valid only when the vessel is operated as a pilot boat and service vessel in the Port of Qubec, between Saint-Jean, le d'Orlans, and Saint-Nicolas. 1.5.2 Personnel The operator of the VZINA NO.1 did not hold a valid certificate at the time of the accident. On 04April 1984, he had been issued a master's certificate for small craft. The certificate was to be renewed each year, but the operator had not done so since 1990. The most recent certificate held by the operator of the VZINA NO.1 was endorsed as follows: This certificate is only valid in pilot vessels not employed in commercial towing operations and operating on the St.Lawrence River between St.Nicholas and St.Jean (Orleans Island) P.Q. The master of the SERVICE BOATII holds a master's certificate for minor waters since1961. 1.6 Personnel History The master of the SERVICE BOATII has been going to sea since 1951, and he has extensive experience of tugs and towing operations and manoeuvres. 1.7 Weather and Tidal Information 1.8 Radio Communications 1.8.1 Inter-Ship During the towing manoeuvres, communications on channel10 of the very high frequency (VHF) radiotelephone were normal. However, when the operator of the VZINA NO.1 transmitted a message to the SERVICE BOATII to advise that he intended to let his vessel be drawn backward, that vessel was already in contact with the MCTS Centre and probably did not hear the message. This would account for the SERVICE BOATII not acknowledging the message from the VZINA NO.1. Within one minute, the operator transmitted an emergency message asking the SERVICE BOATII to stop pulling. 1.8.2 Marine Communications and Traffic Services Centre At 13:42:50, the SERVICE BOATII informed the MCTS Centre in Qubec City, on channel11 of the VHF, that she was proceeding toward Louise Basin. At 13:47:13, the Centre received another message advising that the VZINA NO.1 had capsized, that one crew member had been pulled from the water safe and sound, and that the other was missing. 1.9 Life-saving Equipment 1.10 Search and Rescue The fact that rescue divers are not permanently assigned to CCG SAR vessels, inter alia to aid persons trapped in submerged or semi-submerged vessels, generated significant local public interest after this tragedy. Therefore, the background to CCG policy follows. In 1989, the CCG launched a program assigning teams of divers on board units of the fleet. The objective of this policy was to enhance the fleet's capability to carry out its missions from CCG vessels and bases. Provision of diving services was to be governed by the following parameters: a diving team was to be maintained in each Coast Guard ship or group of ships tasked for duty in the Arctic; diving teams were to be maintained in Type 500 and 600 vessels tasked to conduct primary Search and Rescue (SAR) operations. For purposes of this Order, R Class Cutters were considered to be Type 500 vessels; diving teams could be maintained in other ships if warranted by the ship's role; when no in-house divers were available, each Regional Manager Fleet Systems was to ensure that alternate services were available. This could mean, with the cooperation of Aids and Waterways, diving services provided by diving teams assigned to CCG bases or by commercial firms from the list of firms located near the operations zone. In accordance with the 1989 policy, the STERNE and vessels of her class have never carrieddivers. On 01April 1992, a new CCG policy on diving operations came into effect. This policy called for the discontinuation of all diving operations from CCG vessels, and on 10March 1992, Fleet Systems formally withdrew from diving operations for financial reasons. The cost of maintaining diving equipment, training the divers, and mandatory minimum dive times to keep the divers' certificates valid were factors which were taken into account in view of the economic context. Although teams of divers were withdrawn from fleet vessels, in January 1995, a two-year pilot project was announced to establish a Dive Rescue Unit on the West Coast for marine casualties where divers would be required. The divers were assigned to high-speed hovercraft. The objective of the project was to determine the feasibility and effectiveness of this type of response unit for search and rescue missions. After some 15 months of operation, however, it was still not possible to assess this type of diving operations, as no opportunity had yet arisen to call upon the unit's services. 1.11 Stability The approval criteria set out in STAB. 3 of the CCG Stability, Subdivision, and Load Line Standards, entitled Interim Standard of Stability for Ships Built or Converted for Towing, constitute a reliable yardstick for assessing the stability characteristics of the VZINANO.1. Based on the data from the stability booklet of the VZINA NO.1, dated 1989, the TSB conducted an independent study of the stability of the vessel. The results of this analysis indicate that the vessel meets all stability requirements of the STAB.3 standard. PartVIII of the Hull Construction Regulations outlines the stability requirements for vessels built or converted for towing. As a service vessel of over five tons gross tonnage built before 01April 1972, the VZINA NO.1 is deemed to be an existing ship and is therefore exempt from these requirements.